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Old 03-05-2013, 09:53 AM   #41
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I agree it is a difficult question - but to your quoted point, couldn't you say the same thing with regard to vaccines, antibiotics, or chemotherapy? Where do you draw the line?
You are right. Not an easy question. I don't draw the line. I'm just pointing out another way to look at it. A few religions take the position that we should never intervene (vaccines, CPR, surgery, whatever). But the more common religious argument I hear raised is that life should be extended in all cases (e.g. Terru Schiavo). It just strikes me that they push intervention beyond what their theologies would really counsel if they studied them deeply. By the way, I would not push my views on any old folks who desire intervention in all cases (and a fair number exist). I just think the default ought not be to engage in heroic efforts. That should be something people are given an opportunity to elect in end of life directives rather than the reverse as is the case today. Yeah, I know -- easier said than rationally done.
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Old 03-05-2013, 09:57 AM   #42
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It appears that the patient and her family had communicated their wishes with the staff of the home. But why did the nurse dial 911 if the resident had a DNR? Did she not know, or was it CYA? And having made the call, why did the nurse not make it clear to the dispatcher that the patient had a DNR? Why did the dispatcher not ask?
We don't have enough info to answer all these questions.

I've been reading this with great interest, since my dad is in independent living in a different facility by the same company. I've read his documents and can't find any "no CPR" policy in writing to the residents.

However, they make it clear that when in independent living, you are essentially an apartment dweller. This is not a licensed nursing facility. They do provide extra services by licensed contracted groups, but that is more of a one-on-one contract if you sign up for it. Perhaps this nurse was in the area attending someone else and came by to help or ran into the situation.

So what if you fall on your sidewalk at your apartment complex. What does someone do? Call 911. Similarly, they call 911 in these facilities for all emergencies. They don't call a "code blue" over the intercom and have every nurse within reach come running. That's not how it works. I don't know who called 911. Maybe the front desk. Maybe the lady pulled the panic cord. Not enough information.

With litigation these days, I can actually understand the policy they have for independent living. This is being portrayed as some heartless act. After all, on TV, Dr. House saves everyone. Surely, in a senior residence they should know how to save everyone, no? (I say that sarcastically.)

We need to get a handle on end of life issues. My dad has a DNR. Yet that doesn't mean we don't want him to have any medical treatment. He had life-saving surgery last year for something that had a good degree of success. He recovered. But if he were to have a heart attack at near 90? I don't think so. He's OK with it. My siblings and I are OK with it. He should not get CPR. Please give him comfort first. We've all already gone through the mourning process of where he's at. We're just happy he's with us right now and savor every moment. I know that at any time I could get "that call" ...
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Old 03-05-2013, 10:06 AM   #43
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It appears that the patient and her family had communicated their wishes with the staff of the home. But why did the nurse dial 911 if the resident had a DNR? Did she not know, or was it CYA?
From post #18...
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The executive director of Glenwood Gardens, Jeffrey Toomer, defended the nurse's actions in a statement, saying she did indeed follow policy.

"In the event of a health emergency at this independent living community our practice is to immediately call emergency medical personnel for assistance and to wait with the individual needing attention until such personnel arrives," Toomer said in a written statement. "That is the protocol we followed."

Toomer offered condolences to the woman's family and said a "thorough internal review" of the incident would be conducted.

He told KGET-TV that residents of the home's independent living community are informed of the policy and agree to it when they move in. He said the policy does not apply at the adjacent assisted living and skilled nursing facilities.
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Originally Posted by Meadbh
And having made the call, why did the nurse not make it clear to the dispatcher that the patient had a DNR? Why did the dispatcher not ask? Clearly they had different mental models of the situation and were not communicating. Finally, who took it upon him/herself to share this with the media, under the misapprehension that CPR was the right thing to do? Too much communication again.

The best that could come out of this is improved public and professional awareness of the importance of documenting ones wishes and understanding what that means you won't do when there is a DNR.
Right or wrong, my take on it based on the recording, they were both doing their jobs (very professionally IMO), with cross-purposes. I don't fault either one at all...someone doesn't have to be at fault every time something bad happens.
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Old 03-05-2013, 10:17 AM   #44
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Midpack: good info, and pretty much our understanding. This is one reason that the assisted living is in a different wing.

We're all OK with this policy. As mentioned, what dad would want is "comfort" in an emergency. Having someone be there with him while waiting is really all we ask at this stage of life. And hopefully, they can pass along his DNR wishes.

Which reminds me. We were supposed to put something in his freezer (a standard location) which has the paperwork. I'm not sure we did that or not. Time to call the siblings and find out.
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Old 03-05-2013, 10:17 AM   #45
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It appears that the patient and her family had communicated their wishes with the staff of the home. But why did the nurse dial 911 if the resident had a DNR? Did she not know, or was it CYA? And having made the call, why did the nurse not make it clear to the dispatcher that the patient had a DNR? Why did the dispatcher not ask? Clearly they had different mental models of the situation and were not communicating. Finally, who took it upon him/herself to share this with the media, under the misapprehension that CPR was the right thing to do? Too much communication again.

The best that could come out of this is improved public and professional awareness of the importance of documenting ones wishes and understanding what that means you won't do when there is a DNR.

+1 on this...

It was what I was going to write... if there was a DNR, then no call should have been made at all...


I would want to know if there were other medical problems or not... she seemed to be in the independant living section and not the SNF that I heard reported early on... if she was in the SNF, I would have thought they would have done CPR unless a DNR order was there...
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Old 03-05-2013, 10:28 AM   #46
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It was what I was going to write... if there was a DNR, then no call should have been made at all...
Not enough information. Perhaps she called 911. Perhaps a neighbor. Perhaps she called the front desk or hit the panic and said, "I'm having trouble breathing." In that case, they'll call 911.

They are not going do a medical evaluation and make a call on DNR. Doesn't work that way in independent living. They leave that up to the EMS. So, yeah, you are right. If this was SNF, it would be a whole different story.

The fact that it was a nurse who encountered the lady is the confusion. They send someone to look after a panic situation, but that could just as easily be someone completely unskilled in medical treatment (for independent living).
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Old 03-05-2013, 10:52 AM   #47
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I've read so much and heard so much about this situation that I'm not sure what to think. One thing that caught my ear is that CPR is not considered resusitation. It's not a "violation" of DNR. I also heard that if you perform CPR on someone and something happens like breakiing a rib or similar harm, that you cannot be sued for harming that person. It was also stated that is the case in "most" states. Well what is the truth? This begs for further discussion, disclosure and facts printed for the world to see. I'm confused.
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Old 03-05-2013, 10:54 AM   #48
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It was what I was going to write... if there was a DNR, then no call should have been made at all...
Except that would violate the published agreement they have with all their residents and presumably their families...
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Old 03-05-2013, 10:56 AM   #49
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IMO, the situation in the independent facility was more clear cut than other situations. With both the 911 dispatcher and facility nurse doing their jobs. If either of them did things differently, they could lose their jobs. Plus, even though there was not a DNR, the daughter's view sounds like that was her opinion.

That said, I think that how a nurse is trained to handle things in a hospital vs a nurse from an independent living facility or nursing home is different. I might be wrong, but I wouldn't imagine at a hospital setting, if someone who didn't have a DNR needed a code blue, that they wouldn't try.
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Old 03-05-2013, 11:02 AM   #50
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I've read so much and heard so much about this situation that I'm not sure what to think. I also heard that if you perform CPR on someone and something happens like breakiing a rib or similar harm, that you cannot be sued for harming that person. It was also stated that is the case in "most" states. Well what is the truth? This begs for further discussion, disclosure and facts printed for the world to see. I'm confused.
No one can stop you from bringing a lawsuit against you, but if you Google/Bing you'll find:
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Good Samaritan laws protect people who "gratuitously and in good faith" give CPR or use an AED. There has never been a successful lawsuit in the United States against a person providing first aid/CPR in good faith.
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Q. Can I be sued for providing CPR or First Aid?

A. You are protected by the Good Samaritan Law as long as you do what a normal prudent person would do in an emergency situation. This means: Don't go weird and try to perform invasive procedures, such as cutting open the throat and sticking in a straw to help someone breathe or doing compressions over the throat. Unfortunately you can be sued, but not successfully, as long as you only do what is within your scope of training.

Remember, if some one is not in your care, you must ask permission of the responsive victim if you can help. If they are unresponsive, you have implied consent.

CPR Rescuers, the National Safety and Health Institute (ASHI), the National Safety Council, the American Heart Association and the American Red Cross will all stand behind you if you follow these guidelines.
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Old 03-05-2013, 02:37 PM   #51
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I agree it is a difficult question - but to your quoted point, couldn't you say the same thing with regard to vaccines, antibiotics, or chemotherapy? Where do you draw the line?
Where it touches the speaker.

On the particular case of this patient, if she is guilty of nothing else, this nurse is guilty of colossally bad PR judgment. She likely was only trying to figure out what would be least likely to cost her a job. Another reason it is better to get anything you can afford by private, non-institutional channels. They work directly for you, not for their employing bureaucracy.

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Old 03-05-2013, 05:22 PM   #52
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There hasn't been much discussion of what chest compressions do to an elderly woman. My SIL is in a care facility at this moment suffering from rib fractures from a fall at home, she doen't have a good quality of life. I would do mouth-to-mouth breathing until someone with 'paddles' arrived but chest compressions would not be kind.
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Old 03-06-2013, 12:37 AM   #53
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Some people in their 80s are very happy to be alive.

My mother nearly died of a cardiac problem around that age, but was saved by surgery and is now leading a happy life, taking care of her granddaughters very often, etc. And I'm very glad she's still around.

I'll be turning 45 soon and can't imagine that I would ever want a DNR order, UNLESS my quality of life would become particularly bad. You can't deduce from someone's age that that person doesn't want to be alive as much as you anymore.

In much of the developed world people are living longer than in the past and staying healthy longer. And with medical progress that will hopefully improve even more in the future. I certainly hope people taking care of me in my old age won't assume I'm cool with dying and will do everything they can to keep me alive until I decide I myself that I want to die.
If I am alive in my 80s I will be VERY happy about it but that does not change the fact that CPR is almost always unsuccessful when performed on elderly patients. In this case the patient's daughter who is a nurse said that she was satisfied with the treatment her mother got. Of all the people posting on this forum there are probably only a couple who have participated in more codes than I have. I was usually the guy working up a sweat doing compressions. I worked nights in a teaching hospital and the senior residents often ran codes for extended times to train the medical students and junior residents. CPR was never anything like what you see on television. The very few elderly patients that survived CPR went into the ICUs and ended up on ventilators and always died there.

Edit to add: When we had codes one nurse would call the attending Physiican. We would keep them apprised of the progress of the code and they would sometimes tell the Senior Resident to stop the code. On one occasion I had a patient who was not a DNR arrest while the attending was there and she decided to not call a code. Nurses will sometimes talk about a "slow code" (waiting to make sure the patient is dead before calling a code) but I was never aware of that actually happening.
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Old 03-06-2013, 08:28 AM   #54
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The very few elderly patients that survived CPR went into the ICUs and ended up on ventilators and always died there.
Thanks for this perspective (I've heard it from other sources as well).

What's really bothering me is on the TV/Radio talk I keep hearing the 911 caller being vilified (paraphrasing) 'She had a moral obligation to save that woman's life, and she just refused'. They make it sound so cut and dried - do CPR, save the woman; don't do CPR, she dies. It's clearly not like that.

On one hand, I think the 911 operator did an excellent job in being persuasive and trying to get someone to give the woman CPR (regardless of whether that was a proper response). OTOH, if non-CPR is so typical in these places, I would think that 911 operators would be aware of this? I don't know, maybe their training can't go into that much depth, but there must be a lot of calls from these places, due to the age of the residents, so I'd expect them to be familiar with the protocols.

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Old 03-06-2013, 08:39 AM   #55
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I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.
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Old 03-06-2013, 08:41 AM   #56
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Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.
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Old 03-06-2013, 08:51 AM   #57
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I think I now know of a great tattoo. DNR, right over the old thumper.
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Old 03-06-2013, 09:01 AM   #58
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I just read that the lady did not have a written care directive but gave her family to understand that she would not want CPR.

If I were in charge at a long term care facility, I would make it a condition of admission that all residents have a written care directive on file. I think many facilities do that.
From what I've heard/read, the residents sign a document that states they accept that the facility does not provide CPR. Hopefully that's not buried in fine print, but they are agreeing to it if they sign.

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Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.
Who is agreeing based on $? CPR has poor outcomes, esp for older people.

But the more expensive assisted care centers have more medically trained people around (and have to charge for it). These people might be in a better position to determine if CPR is appropriate or not for an individual. What can you expect? How about every older person living at home, or every person with a higher-than-average coronary risk profile be accompanied 24/7/365 by a trained EMT? Not really practical is it? Where do you draw the line? Those $ would be better applied elsewhere.

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Old 03-06-2013, 09:03 AM   #59
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Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.
But many residents of asisted living would have DNRs on file and would not be resuscitated. I suspect many, if not most, require an advance directive upon entrance. For people who do not have a DNR, the very concept of assisted living means they have expectations of trained help readily available. From the various articles, residents of independent living sign agreements that they will not get CPR until EMTs arrive. I don't see any contradiction here.
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Old 03-06-2013, 09:04 AM   #60
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Interesting that so many seem to agree with the policy of withholding CPR to residents of the less expensive "independent" living section, when it would have been provided as a matter of policy to residents of the more expensive "assisted" living section.
Some of us know individuals who are adamant about not being resuscitated. Difficult as it may be, some individuals choose facilities specifically because they feel confident their DNAR request will be honored. Glenwood Gardens Independent Living policies in place were published when this story first broke, they seemed very clear. The facility seems to be highly regarded if the online references before and after this story are any indication.

That said, there still seems to be some confusion about the exact circumstances in this case. If it's true as widely reported that her daughter was satisfied with the care her mother received, that carries far more weight than all the third party opinions floating around IMHO.

The elderly woman's passing is sad no matter what, 87 years old or not. And I don't think the nurse or the 911 dispatcher did anything wrong, they both did their best to fulfill their responsibilities from what I've heard. They were at cross-purposes, that doesn't necessarily mean either were at fault/to blame. YMMV
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